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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 565801454
Report Date: 09/05/2024
Date Signed: 09/05/2024 01:32:21 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/30/2024 and conducted by Evaluator Emily Peraldi
COMPLAINT CONTROL NUMBER: 29-AS-20240830142447
FACILITY NAME:ARLENE'S RESIDENTIAL CARE HOMEFACILITY NUMBER:
565801454
ADMINISTRATOR:CHARITO F RAMIREZFACILITY TYPE:
735
ADDRESS:4321 BROWNING DRIVETELEPHONE:
(805) 488-0322
CITY:OXNARDSTATE: CAZIP CODE:
93033
CAPACITY:6CENSUS: 5DATE:
09/05/2024
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Charito Ramirez, AdministratorTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Residents are being left alone without supervsion.
Residents are not being provided sufficient amount of food.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced initial complaint visit to this facility. At 9:30 a.m., the LPA met with clients. At 9:40 a.m., staff arrived at the facility. At 9:44 a.m., the LPA spoke with the Administrator, Charito Ramirez and explained the reason for the visit.

Starting at 9:33 a.m., the LPA conducted interviews with the Administrator, one (1) staff and two (2) clients. At 9:50 a.m., the LPA along with staff conducted a physical plant tour. At 1:17 p.m., the LPA obtained copies of pertinent documents.

Continued on LIC 9099-C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 29-AS-20240830142447
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ARLENE'S RESIDENTIAL CARE HOME
FACILITY NUMBER: 565801454
VISIT DATE: 09/05/2024
NARRATIVE
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Regarding the allegation: 1.) Residents are being left alone without supervision. On 08/30/2024, the Department received a complaint alleging that staff leave the facility, leaving clients unattended. During today’s visit, the LPA arrived at the facility at 9:30 a.m. and observed two (2) clients inside the facility and no staff present. Upon the LPA’s arrival, Client #1 (C1) called Staff #1 (S1) and notified S1 that Licensing was at the facility. At 9:40 a.m., S1 arrived at the facility. S1 stated that they were picking up breakfast and intended to return to the facility within 10-15 minutes. The LPA spoke with S1 and the Administrator over the telephone and reminded them that leaving the clients without supervision is an immediate health and safety concern. Based on observation, the preponderance of evidence standard has been met, therefore the above allegation is deemed Substantiated.

Regarding the allegation: 2.) Residents are not being provided sufficient amount of food. On 08/30/2024, the Department received a complaint alleging that clients are not provided with three (3) meals a day and snacks. During today’s visit, the LPA observed the kitchen and additional food supply located in the garage. The LPA observed insufficient amount of food and snacks for five (5) clients. The LPA observed the refrigerator in the kitchen to have applesauce, soda cans, two (2) cartons of milk, condiments and boxes with leftover food. The LPA observed the freezer to have frozen meat such as chicken and sausages. The LPA observed grapes on the dining table. During the time of the visit, the LPA pointed out to S1 the lack of fruits and vegetables and S1 brought out two (2) bags of apples, and one (1) bag of nectarines to the dining table. The LPA had several conversations with S1 and the Administrator of the importance of having sufficient amount of food available to the clients, including at least three (3) meals per day and snacks. Based on observation, the preponderance of evidence standard has been met, therefore the above allegation is deemed Substantiated.

Per the California Code of Regulations, Title 22, and California Health and Safety Code, the following deficiencies were observed and cited during the visit (See 9099-D). Civil penalty issued for the amount of $1,000. The Administrator was advised that failure to correct the deficiencies may result in additional civil penalties.

Exit interview conducted. A copy of the report, civil penalty and appeal rights were provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 29-AS-20240830142447
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ARLENE'S RESIDENTIAL CARE HOME
FACILITY NUMBER: 565801454
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/06/2024
Section Cited
CCR
80078(a)
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80078 Responsibility for Providing Care and Supervision (a)The licensee shall provide care and supervision as necessary to meet the client's needs.This requirement is not met as evidenced by:
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Administrator agrees they will not leave clients unsupervised. Administrator stated that she will submit a statement of understanding of CCR 80078, along with LIC500 with specific days and hours shown for all staff.
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Based on observations, the licensee did not comply with the section cited above as two (2) clients were alone at the facility without any staff supervision at 9:30 a.m. on 09/05/24 which poses an immediate health and safety risk to clients in care.
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Civil penalty in the amount of $1,000 assessed.
Type B
09/13/2024
Section Cited
CCR
80076(a)(1)
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80076 Food Services (a) In facilities providing meals to clients, the following shall apply: (1) All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients...This requirement is not met as evidenced by:
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The Administrator stated she will conduct a food audit of the food supply and ensure that there will be sufficient amount of food and snacks for all five (5) clients. Administrator will submit proof to CCL by due date.
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Based on observation, the licensee did not comply with the section cited above in insufficient food and snacks was observed on 09/05/2024 which poses a potential health and safety risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3